Provision of Substance Use Disorder Treatment in Medicaid Health Homes

Background: Established as part of the Affordable Care Act, the Medicaid health home program is an innovative service delivery model for Medicaid enrollees with chronic health conditions. The health home program enables states to contract with teams of health care providers to provide comprehensive, coordinated services, with the goal to improve quality of care.  To date, 21 states have established 35 unique health home plans, serving more than one million enrollees. Health homes have a strong focus on behavioral health and thus possess the potential to improve the delivery of substance use disorder treatment. The current study adds to the literature by assessing what strategies health homes are using to identify and treat substance use. Given that social workers are the largest provider of substance use disorder treatment nationally, it is critical to understand how these services are being provided within the context of this growing, innovative model of service delivery.

Methods: We conducted a content analysis of the population of State Plan Amendments approved by the Centers for Medicare and Medicaid Services (n=35), which provide detailed descriptions of each health home plan. Two independent reviewers extracted information from the amendments across several domains: addiction screening; inclusion of substance use disorder treatment providers within provider care teams; co-location of substance use disorder treatment in primary care; and monitoring of addiction outcomes.  An additional researcher compared reviewers’ coding, and identified and resolved discrepancies in collaboration with the entire research team. Descriptive statistics were computed using Stata 14.1

Results: Study findings indicate that only 4.8% of health home plans required co-location of primary care and behavioral health services in their Medicaid health home plans; none explicitly required substance use disorder treatment to be co-located. Among health home plans that were not co-located, 70% required health homes to coordinate with a behavioral health specialist, but only 21.4% explicitly required the inclusion of substance use expertise. Only 23.8% of plans allowed social workers to receive reimbursement on health home provider teams. Overall, 38.1% of plans required routine screening for substance use disorder, and 38.1% required providers to monitor provider performance on addiction-related outcomes.

Implications:  Given the high prevalence of substance use disorder within the Medicaid population, and substantial comorbidity of substance use with other chronic health conditions, health homes offer an opportunity to greatly improve accessibility and quality of treatment. However, the findings of this study indicate that most health homes do not require providers to screen for substance use, or ensure that health home provider teams include a professional with requisite knowledge and expertise to treat it. State Medicaid agencies should consider revising their State Plan Amendments to require routine screening for addiction, and inclusion of qualified substance use disorder treatment professionals. As the largest provider of substance use disorder treatment services in the United States, social workers should be at the forefront of these efforts, advocating for the profession’s inclusion in these quickly proliferating state health home plans and ensuring the availability of substance use disorder treatment that is integrated and effective.